a nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x ray department which of
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Nursing Elites

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ATI Detailed Answer Key Medical Surgical

1. A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Correct answer: C

Rationale: When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.

2. A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

Correct answer: B

Rationale: The absence of fluctuations in the water seal chamber indicates that the client's lung has re-expanded. This finding suggests that the negative pressure in the pleural space is restored, preventing air from entering the system. Oxygen saturation, absence of pleuritic chest pain, and occasional bubbling in the water-seal chamber are important assessments but do not specifically indicate lung re-expansion.

3. A client is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?

Correct answer: C

Rationale: Choosing a hospital accredited by The Joint Commission (TJC) or another accrediting body is the best advice as it ensures a focus on safety and quality standards.

4. In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?

Correct answer: A

Rationale: In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.

5. A healthcare professional is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the professional expect to hear?

Correct answer: A

Rationale: When auscultating the lungs of a client with pleurisy, the healthcare professional should expect to hear loud, scratchy sounds. These sounds are characteristic of pleurisy, which is an inflammation of the pleura, causing a rough, grating sound during breathing.

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